The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute.

Which medication should the nurse withhold until the healthcare provider is notified?

Digoxin.

Furosemide.

Hydralazine.

Enalapril.

Answer and Explanation

The Correct Answer is A

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

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Correct Answer is A

Explanation

The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause

A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.

A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.

Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.

A. Suggest placing the iron drops in the orange juice and then feeding the infant. B. Give the mother positive feedback about the way she administered the medication. C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops. D. Tell the mother to follow the iron drops with infant formula instead of orange juice.

Correct Answer is B

Explanation

The nurse should give the mother positive feedback about the way she administered the medication. Giving the infant orange juice after administering the iron drops is a good practice because vitamin C in the orange juice can enhance the absorption of iron. The other options (A, C, and D) are not appropriate actions for the nurse to take in this situation.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

Correct Answer is B

Explanation

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A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

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When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?

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